Provider Demographics
NPI:1588700322
Name:MARTINEZ, ROBERTO M (SLP)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:M
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 890
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76703-0890
Mailing Address - Country:US
Mailing Address - Phone:254-297-7124
Mailing Address - Fax:254-297-7124
Practice Address - Street 1:110 S 12TH ST
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76701-1810
Practice Address - Country:US
Practice Address - Phone:254-297-7124
Practice Address - Fax:254-756-3133
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15674235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX084859002Medicaid